Colonial Terrace Care Center
1320 Northeast 1st Place, Pryor, OK 74362 · For profit - Limited Liability company · 75 certified beds · (918) 825-5311 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.6% | 13.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.9% | 3.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.9% | 1.9% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 0.7% | 2.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 3.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.0% | 4.7% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 10.3% | 13.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 35.2% | 25.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.6% | 4.7% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 10.8% | 17.1% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.8% | 17.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.0% | 1.8% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 82.6% | 74.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 27.8% | 27.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.2% | 16.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 3.10 | 2.31 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.04 | 2.96 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.62 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 28% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 7.5–15.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 65.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.5%CMS range 4.1–14.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.36 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 75 beds and averages 39.4 residents a day — about 53% occupied, or roughly 36 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Weekend coverage: total nurse staffing is 3.25 hrs/resident/day on weekends vs 3.22 on weekdays — about the same on weekends as weekdays. RN hours go from 0.22 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 55% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · Dcited before2026-04-16 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a physician responded to a pharmacy consult report regarding the prescription of an antipsychotic medication for the diagnosis of dementia for 1 (#7) of 6 sampled residents reviewed for unnecessary medications.The DON reported 30 residents at the facility had been prescribed psychotropic medications.Findings:A quarterly assessment, dated 02/02/26, showed Res #7 had a BIMS score of three (a BIMS score of three shows Res #7's cognition was severely impaired) and had been administered antipsychotic medication. A pharmacy consultation report titled Expanded DRR Report, dated 02/18/26, read in part, Seroquel [antipsychotic medication] is FDA [Federal Drug Administration]-approved for schizophrenia, bipolar disorder (mania, depression, maintenance), and as adjunct therapy in major depressive disorder (MDD). It is not approved for dementia-related psychosis. Please verify/update diagnosis and document rationale for antipsychotic usage. The consultation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-16 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure medications that required refrigeration were stored at the appropriate temperature and controlled substances were stored in securely locked containers for 2 (medication room refrigerator and the DON's office) of 2 sampled medication storage areas reviewed for safe storage.The DON reported that seven residents were administered medications that required refrigeration at specific temperatures and 29 residents were administered controlled medications at the facility.Findings:On 04/16/26 at 8:33 a.m., the facility medication room was observed to have a small refrigerator that contained a cardboard box of medication and did not have a temperature log for the date of 04/16/26. The medication observed in the box was tuberculin purified derivative (sterile, diluted protein solution injected intradermally to test for Mycobacterium tuberculosis infection) and the thermometer inside the medication refrigerator read 50 degrees (F).On 04/16/26 at 9:35 a.m., the DON's office was observed while the DON was present.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-21 · tag F0580 — failed to tell family and doctor about changes — patternImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure resident representatives were notified of change for one (#32) of one sampled resident reviewed for notification of change. The administrator identified 39 residents who resided in the facility. Findings: The undated Notification of Change policy, read in parts, .The nurse will immediately notify the resident .resident representative for the following [list is not all inclusive]: A need to alter treatment significantly [a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment] .Document the notification and record any new orders in the resident's medical record . Resident #32 had diagnoses which included dementia, recurrent depressive disorders, and constipation. The Medication Administration Record, dated 01/01/24 through 01/31/24, documented the resident's Zoloft was increased from 25 mg daily to 50 mg daily for depression on 01/18/24 and had been ordered Namenda 5mg twice daily for dementia on 01/19/24. A Progress Note, dated 01/19/24,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-21 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure residents were administered the correct doses of medications ordered by their physician for two (#19 and #93) of six sampled residents reviewed for medication administration. A facility resident roster, dated 06/17/24, documented 39 residents resided at the facility. Findings: An Adverse Consequences and Medication Errors policy, dated 2001, read in part, A medication error is defined as the preparation or administrator of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 1. Resident #19 had diagnoses which included acute kidney failure and diabetes mellitus with diabetic neuropathy. A Medications Administration Record for Resident #19, dated 06/01/24 - 06/18/24, documented the resident was to be administered five units of lispro insulin from a 200 unit per milliliter strength insulin pen before each meal. The order had a start date of 01/09/24 and an open end…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-06-21 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than five percent. A facility resident roster, dated 06/17/24, documented 39 residents resided at the facility. Findings: An Adverse Consequences and Medication Errors policy, dated 2001, read in part, A medication error is defined as the preparation or administrator of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. A Treatments Administration History form for Resident #19, dated 06/01/24 - 06/19/24, read in part, Humalog KwikPen Insulin (insulin lispro) Insulin pen; 200 unit/mL (3 mL); Amount to administer: 5 units; subcutaneous .The form further documented the resident received the afternoon dose of the medication on 06/18/24. A Medication Administration Record form for Resident #93, dated 06/01/24 - 06/20/24, read in part, sotalol tablet; 120 mg; Amount to Administer: 1 tab; gastric tube . The form further documented the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-06-21 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure the ice machine was maintained in a sanitary manner for one of one ice machines observed. Corporate nurse #1 identified 38 residents who received nourishment from the kitchen. Findings: The untitled, undated policy, read in parts, .It is the policy .that ice machines will be cleaned weekly and as needed. Maintenance will clean ice machine at a minimum of weekly . The Ice Machine Log, dated June 2024, documented the ice machine had been cleaned on 06/03/24, 06/10/24, and 06/17/24. On 06/17/24 at 9:02 a.m., the ice machine was observed with the dietary manager. The deflector panel on the inside of the ice machine was observed to contain a black/brown substance that was easily wiped off with a paper towel. The dietary manager stated the maintenance supervisor was responsible to clean the ice machine. The coil cover in the top portion of the ice machine was observed to contain a orange/yellow substance that was easily wiped with a paper towel. On 06/17/24 at 9:05 a.m., the maintenance supervisor stated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-21 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure indwelling urinary catheter tubing was placed to maintain infection control for one (#16) of one sampled resident who had an indwelling urinary catheter. Corporate nurse #1 identified one resident who had an indwelling urinary catheter. Findings: Resident #16 had diagnoses which included neuromuscular dysfunction of the bladder, retention of urine, and history of urinary tract infection. The quarterly assessment, dated 05/03/24, documented the resident had an indwelling urinary catheter and required maximal assistance for transfers to the chair. On 06/18/24 at 9:15 a.m., Resident #16 was observed in the hall in their wheel chair. The catheter tubing was observed to touch the floor. On 06/19/24 at 8:42 a.m., Resident #16 was observed in their room sitting in their wheel chair. They stated they were totally dependent on staff for transfers. The catheter tubing was observed to touch the floor. On 06/19/24 at 11:29 a.m., Resident #16 was observed by the nurses station in their wheel chair. The catheter…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-21 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure pain medication was administered per the physician's order for one (#1) of six sampled residents whose medications were reviewed. Corporate nurse #1 identified 29 residents on routine pain medication. Findings: Resident #1 had diagnoses which included neuropathy. The Care Plan, dated 02/21/24, documented to administer pain medication as ordered by the physician. The Prescription Order, dated 03/16/24, documented the resident had been ordered diclofenac sodium 1% (a pain reliever) topically to bilateral feet twice daily. The Treatment Administration History, dated 04/01/24 through 04/30/24, did not contain documentation the diclofenac had been administered on 04/08/24 for the a.m. shift or 04/11/24 for the a.m. or p.m. shift. The Treatment Administration History, dated 05/30/24, did not contain documentation the diclofenac had been administered on the a.m. or p.m. shift. The Treatment Administration History, dated 06/10/24, did not contain documentation the diclofenac had been administered on the p.m. shift. Review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-11 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to promote resident dignity by staff standing over residents while assisting them to eat for two (#9 and #11) of three sampled residents reviewed for dignity. The administrator identified 38 residents resided in the facility. Findings: 1. Res #9 had diagnoses which included achondroplasia. A significant change assessment, dated 03/15/24, documented the resident's cognition was severly impaired and they required partial/moderate assistance with eating. On 04/10/24 at 8:18 a.m., CNA #3 was observed standing over the resident in the dining room while assisting them to eat their breakfast. On 04/10/24 at 8:31 a.m., CNA #3 was asked asked what was the protocol for assisting residents with eating. They stated they should sit next to the residents while assisting them with their meals. They were asked if they sat while assisting Res #9 with their breakfast. They stated they did not sit. 2. Res #11 had diagnoses which included CHF, SOB, diabetes, and seizures. A quarterly assessment, dated 01/17/24, documented the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-05-17 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure an RN worked seven days a week, eight hours a day, for nine of nine days reviewed. The Resident Census and Conditions of Residents report, dated 05/09/23, documented 48 residents resided in the facility. Findings: The PBJ report for quarter one, documented no RN hours were reported for 11/09/22, 11/19/22, 11/20/22, 11/26/22, 11/27/22, 12/03/22, 12/10/22, 12/24/22, and 12/25/22. On 05/17/23 at 2:35 p.m., documentation of RN coverage was requested for the above dates from the BOM. On 05/17/23 at 2:50 p.m., the BOM stated they did not have any RNs who worked on the provided dates. They stated neither of the core facility RNs clocked in and they did not have agency RNs that were working in the facility. On 05/17/23 at 2:53 p.m., the administrator was asked what the facility protocol was regarding RN coverage. They stated there would be an RN seven days a week, eight hours per day. The administrator was asked who was responsible to ensure RN coverage. They stated the administrator and the DON. The administrator was asked…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · E2023-05-17 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to complete comprehensive care plans for five (#2, 10, 26, 31, and #34) of 12 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents report, dated 05/09/23, documented 48 residents resided in the facility. Findings: The Care Plans, Comprehensive Person-Centered policy, dated December 2016, read in part, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 1. Resident #2 had diagnoses which included congestive heart failure. The quarterly assessment, dated 04/03/23, documented the resident was moderately impaired in cognition for daily decision making and required extensive assistance from staff for bed mobility. The assessment was not coded to indicate the resident utilized side rails. On 05/09/23 at 4:34 p.m., the resident was observed in bed with a half side rail in the raised position on the left side of the bed. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-05-17 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure residents with bed rails were assessed for the use for three (#2, 26, and #31) of three sampled residents who were reviewed for bed rails. Corporate Nurse #1 identified nine residents who utilized bed rails. Findings: The Proper Use of Side Rails policy, dated December 2016, read in part, .An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails .The use of side rails as an assistive device will be addressed in the resident care plan .Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails . 1. Resident #2 had diagnoses which included congestive heart failure. The quarterly assessment, dated 04/03/23, documented the resident was moderately impaired in cognition for daily decision making and required extensive assistance from staff for bed mobility. The assessment was not coded to indicate the use of half side rails. The Care Plan, revised 04/05/23, did not reveal a care plan had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-05-17 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure pharmacy recommendations were addressed by the physician and implemented for four (#7, 17, 18, and #42) of five sampled residents reviewed for unnecessary medications. Corporate Nurse #1 identified 48 residents who received medications. Findings: An undated Drug Regimen Review Policy, read in parts, .The attending physician will document in the resident record, that the identified irregularity has been reviewed and what, if any action has been taken to address it. If the physician chooses not to act upon the pharmacy consultant recommendations, the physician must document rationale as to why the change is not indicated in the resident record . 1. Resident #7 had diagnoses which included depression. A Medication Regimen Review, dated 03/29/23, documented a recommendation to add Famotidine 20 mg twice a day or Omeprazole 20 mg every day. The physician addressed and agreed with the recommendation. Review of the clinical record revealed the facility had not implemented the recommendation for Resident #7. 2. Resident #18…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-05-17 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure the ice machine was maintained in a sanitary manner for one of one ice machines observed and failed to ensure foods were prepared in a sanitary manner for one (the evening meal) of one meal preparation observed. Corporate Nurse #1 identified 48 residents who received nourishment from the kitchen. Findings: The undated Policy & Procedure for Ice Machine Maintenance & Cleaning policy, read in part, .Cleaning to be performed Quarterly or as deemed necessary .Use clean rags or disposable wipes to scrub all surfaces/including the ice storage compartments with ice machine cleaner or fresh distilled vinegar solutions .Clean reservoir and hoses .Clean condenser . 1. The Weekly Ice Machine Maintenance log entry, dated 04/12/23, read in part, .Wiped down and checked machine-it is clean . The Weekly Ice Machine Maintenance log entry, dated 04/19/23, read in part, .Wiped down splash curtain . The Weekly Ice Machine Maintenance log did not reveal any further monitoring/cleaning after 04/19/23. On 05/09/23 at 9:50…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-05-17 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to implement the facility's antibiotic stewardship program. The Resident Census and Conditions of Residents report, dated 05/09/23, documented 48 residents resided in the facility. Findings: An Infection Prevention and Control Program policy, revised October 2018, read in parts, .Culture reports, sensitivity data, and antibiotic usage review are included in surveillance activities .Medical criteria and standardized definitions of infections are used to help recognize and manage infections . A review of the facility's antibiotic stewardship and surveillance book did not reveal antibiotic use protocols or an active system to monitor antibiotic use had been documented. On 05/15/23 at 1:46 p.m., Corporate Nurse #1, was asked to provide the antibiotic stewardship. They stated they were not doing it and it had been a year since it was last done. They stated the antibiotic surveillance and stewardship was to be documented in the electronic clinical record, but they had not been completing it.
- Potential for harm · E2023-05-17 · tag F0909 — failed to maintain a comfortable temperature — patternRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure residents' beds were maintained when bed rails were utilized for three (#2, 26, and #31) of three sampled residents who were reviewed for bed rails. Corporate nurse #1 identified nine residents who utilized bed rails. Findings: The Bed Safety policy, dated December 2007, read in parts, .Ensure that bed side rails are properly installed .The maintenance department shall provide a copy of inspections to the administrator .If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative . 1. Resident #2 had diagnoses which included congestive heart failure. On 05/09/23 at 4:34 p.m., the resident was observed in bed with a half bed rail in the raised position on the left side of the bed. On 05/10/23 at 10:49 a.m., the resident was observed in bed with a half bed rail in the raised position on the left side of the bed. On 05/15/23 at 11:12 a.m., the resident stated when they pulled on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-17 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure code status was accurate for one (#37) of one sampled residents who were reviewed for advance directives. The Resident Census and Conditions of Residents report, dated 05/09/23, documented 48 residents resided in the facility. Findings: The Do Not Resuscitate Order policy, dated April 2017, read in part, .Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident's medical record . Resident #37 had diagnoses which included chronic obstructive pulmonary disease. The Care Plan, dated 10/03/22, documented the resident had a DNR. Review of the electronic face sheet for Resident #37 revealed the code status was DNR. A signed DNR, dated 10/04/22, was observed in the electronic clinical record. A Physician's Order, dated 02/23/23, documented the resident was a full code. On 05/15/23 at 2:13 p.m., RN #1 was asked where the code status' were documented. They stated they referred to the electronic clinical record or the code status binder at the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-17 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to request a level II PASARR for one (#23) of one sampled resident reviewed for level II PASARRs. Corporate Nurse #1 identified eight residents with level two PASARR assessments who resided in the facility. Findings: Resident #23 had diagnoses which included anxiety, major depressive disorder, and schizophrenia. An admission assessment, dated 06/10/21, documented Resident #23 had a diagnosis of schizophrenia. A level I PASARR, dated 06/11/21, documented Resident #23 had no diagnosis of serious mental illness. An annual assessment, dated 05/02/23, documented Resident #23 had diagnoses which included depression, schizophrenia, and anxiety. Section A question A1500 asked if Resident #23 was currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition. The selected answer was no. Resident #23 did not have a completed level II PASARR in the clinical record. On 05/16/23 at 9:40 a.m., Corporate Nurse #1 was asked what diagnosis of mental disorder was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-17 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure baseline care plans were completed for two (#10 and #37) of four sampled residents reviewed for baseline care plans within 48 hours of admission. Corporate Nurse #1 identified 17 residents who were admitted to the facility in the past six months. Findings: The policy Care Plans - Baseline, dated December 2016, read in parts, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight .hours of admission . 1. Resident #10 was admitted on [DATE] and had diagnoses which included chronic obstructive pulmonary disease. Review of the clinical record did not reveal a baseline care plan had been developed for the resident. On 05/12/23 at 4:50 p.m., the MDS coordinator was asked who was responsible to develop baseline care plans. They stated they were responsible. They were asked where the baseline care plan was documented for Resident #10. They stated a baseline care plan had not been developed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-17 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure care plans were reviewed and revised after a quarterly assessment for one (#42) of twelve sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents report, dated 05/09/23, documented 48 residents resided at the facility. Findings: A Care Plans, Comprehensive Person-Centered policy, dated December 2016, read in part, .The interdisciplinary team must review and update the care plan .at least quarterly, in conjunction with the required quarterly MDS assessment . Resident #42 had diagnoses which included Alzheimer's disease, schizophrenia, and anxiety disorder. Review of the clinical record revealed the care plan for Resident #42 was last revised on 01/23/23. A review of the clinical record for Resident #42 revealed a quarterly assessment was completed on 03/16/23. On 05/17/23 at 2:38 p.m., the MDS coordinator was asked when the care plan for Resident #42 was revised. They reviewed the electronic record and stated 01/23/23, but Resident #42 had a comprehensive assessment on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-17 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a discharge summary which included a recapitulation of the resident's stay was completed for one (#51) of one sampled resident reviewed for a resident initiated discharge from the facility. Corporate Nurse #1 identified five residents who were discharged in the past three months. Findings: A Discharge Summary and Plan policy, dated December 2016, read in part, .The discharge summary will include a recapitulation of the resident's stay .shall include a description of the resident's: current diagnosis; medical history .course of illness, treatment and/or therapy; current laboratory .and diagnostic test results .special treatments or procedures .mental and psychosocial status .rehabilitation potential .cognitive status .and medication therapy . Resident #51 had diagnoses which included benign neoplasm of cerebral meninges (a treatable brain tumor). A Discharge Summary, dated 04/28/23, documented an incomplete recapitulation for Resident #51. The recapitulation did not include the reason for discharge, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to assess and monitor pressure ulcers for one (#34) of one sampled resident who was reviewed for pressure ulcers. The Resident Census and Condition Residents report, dated 05/09/23, documented two residents had pressure ulcers. Findings: The Pressure Ulcers/Skin Breakdown-Clinical Protocol policy, dated April 2018, read in part, .the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue . Resident #34 had diagnoses which included pressure ulcer of unspecified heel, heart failure, and paraplegia. A Physician's Order, dated 10/26/22, documented a skin assessment was to be completed on the day shift every Wednesday. The significant change assessment, dated 01/23/23, documented the resident was at risk for pressure ulcers. The TAR, dated March 2023, documented the weekly skin assessments and wound care treatments had been completed as ordered. The Weekly Skin Integrity Review, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure urinary catheter care was performed to prevent the risk of infection for one (#7) of three sampled residents reviewed for urinary catheter care. The Resident Census and Conditions of Residents report, dated 05/09/23, documented four residents had urinary catheters that resided in the facility. Findings: The Catheter Care, Urinary policy, dated September 2014, read in part, .The following information should be recorded in the resident's medical record .the date and time that catheter care was given .the name and title of individual(s) giving the catheter care .all assessment data obtained when giving catheter care . Resident #7 had diagnoses which included benign prostatic hyperplasia with lower urinary tract symptoms. A Physician's Order, dated 03/17/23, instructed to change the urinary catheter every month and as need for obstruction/occlusion on the 17th of the month. An admission assessment, dated 03/24/23, documented the resident had a urinary catheter. The Care Plan, revised 04/17/23, documented Resident #7 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure oxygen humidification bottles were maintained for two (#2 and #31) of three sampled residents who were reviewed for oxygen. Corporate nurse #1 identified nine residents who utilized supplemental oxygen. Findings: 1. Resident #2 had diagnoses which included chronic obstructive pulmonary disease and dependence on supplemental oxygen. A Physician's Order, dated 08/01/22, documented the resident required three liters of oxygen via nasal cannula 24 hours a day. A Physician's Order, dated 02/23/23, documented the CMA was to change out all oxygen tubing and the humidification bottle every Monday on the day shift. The March 2023 and April 2023 TARs documented the oxygen tubing and humidification bottle had been changed seven out of eight opportunities. The 03/20/23 entry on the TAR documented the CMA had not had time to change the oxygen tubing or humidification bottle. The May 2023 TAR documented the oxygen tubing and humidification bottle was changed on 05/01/23 and 05/08/23. On 05/10/23 at 11:18 a.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-17 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure a medication error rate of 5% or less. The facility had a 5.41% medication error rate when two medication errors were observed out of 37 opportunities. Findings: A physician order, dated 07/17/22, documented an order for Loratidine (an antihistamine) 10 mg by mouth once a day. A physician order, dated 03/08/23, documented an order for Lamotrigine 50 mg by mouth twice daily. On 05/12/23 at 9:16 a.m., CMA #2 was observed to administer Cetirizine (an antihistamine) 10 mg by mouth and Lamotrigine (an anticonvulsant medication) 25 mg by mouth to Resident #17. On 05/12/23 at 11:33 a.m., CMA #2 was asked what antihistamine had been administered to the resident. They reviewed the medication bottle and stated Cetirizine was administered. They were asked why Cetirizine was administered rather than the ordered Loratidine. They stated they utilized the house stock supply of Cetirizine and should have administered Loratidine from the pharmacy provided card of medication for Resident #17. CMA #2 was asked what the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-17 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined the facility failed to ensure complete documentation for meal percentages for two (#37 and #10) of two sampled residents who were reviewed for nutrition. The Resident Census and Conditions of Residents report, dated 05/09/23, identified 48 residents resided in the facility. Findings: 1. Resident #37 had diagnoses which included chronic obstructive pulmonary disease. A Physician's Order, dated 02/23/23, read in parts, .Document amount consumed for breakfast .Document amount consumed for dinner .Document amount consumed for lunch . 2. Resident #10 had diagnoses which included dysphagia. A Physician's Order, dated 11/21/22, read in parts, .Document amount consumed for breakfast .Document amount consumed for dinner .Document amount consumed for lunch . On 05/12/23 at 3:16 p.m., CNA #4 was asked where meal percentages were documented. They stated in the electronic clinical record. They were asked who was responsible to document meal percentages. They stated they thought the CNAs were to document but they were not sure. On 05/15/23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to BGM ESTATE — 15 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 1.8 | +1.2 vs chain |
| Health inspection | 4 of 5 | 2.1 | +1.9 vs chain |
| Staffing | 1 of 5 | 2.1 | -1.1 vs chain |
| Quality measures | 4 of 5 | 2.5 | +1.5 vs chain |
The other 14 homes this chain runs (chain average 1.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ANGELUS HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 13% | since 12/12/2025 |
| BGM ESTATE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 38% | since 11/01/2012 |
| PHILIP MARION GREEN EXEMPT TR CU GILBERT F GREEN TR | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 11% | since 12/12/2025 |
| TIFFANY SEAY EXEMPT TR | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 14% | since 12/12/2025 |
| MITCHELL, KELLY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 9% | since 12/06/2021 |
| MITCHELL, MARCINDA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 9% | since 12/06/2021 |
| MITCHELL, ROBERT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 9% | since 12/06/2021 |
| TABOR, ANGELA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 9% | since 12/06/2021 |
| BELT, MIRANDA | Individual | CORPORATE OFFICER | — | since 12/09/2024 |
| PITTS, JACI | Individual | CORPORATE OFFICER | — | since 12/09/2024 |
| TAYLOR, SANDRA | Individual | CORPORATE OFFICER | — | since 12/21/2012 |
| BLALOCK, RANDY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/05/2022 |
| BROWN, JACK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/01/2019 |
| COATNEY, JODI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2022 |
| COOPER-KROPS, LENA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/30/2024 |
| DRYWATER, DECEMBER | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/31/2023 |
| GULLY, KATHY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/10/2023 |
| HUNT, JANA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/28/2022 |
| SINKS, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/17/2024 |
| PHILIP M. GREEN REVOCABLE TRUST | Organization | ADP OF THE SNF | — | since 12/12/2025 |
CMS files one row per role, so the 29 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $344K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OK
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375299. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-16, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
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